Krane Right robotic-assisted adrenalectomy

OPERATION DATE: 08/15/2019 PREOPERATIVE DIAGNOSES: 1. Right adrenal mass. 2. Hyperaldosteronism. 3. Morbid obesity (BMI 44.59). POSTOPERATIVE DIAGNOSES: 1. Right adrenal mass. 2. Hyperaldosteronism. 3. Morbid obesity (BMI 44.59). PROCEDURES PERFORMED: 1. Right robotic-assisted adrenalectomy. 2. Insertion of Foley catheter by MD under general anesthesia. SURGEON: Louis Krane, MD ASSISTANT: 1. Jonathan Zurawin, MD (R) 2. Christopher Koller, MD (R) ANESTHESIA: General and local. FINDINGS: 1. Renal vein with 2 visualized branches. 2. Adrenal gland resected without difficulty in its entirety. 3. Otherwise, normal anatomy. COMPLICATIONS: None. ESTIMATED BLOOD LOSS: 20 mL. SPECIMENS REMOVED: Right adrenal gland. DRAINS: None. TUBES: None. IMPLANTS: None. INDICATIONS FOR PROCEDURE: The patient is a 52-year-old gentleman who was referred for right adrenalectomy. He was diagnosed with hyperaldosteronism. He had adrenal vein sampling done at the University of Mississippi, which revealed right-sided aldosterone producing lesion. There was no visualized mass on CT scan; however, due to these findings, it was recommended that he undergo removal of adrenal gland. Risks, benefits, and alternatives of robotic-assisted adrenalectomy were discussed with the patient in great detail. All questions were answered and informed consents were obtained. PROCEDURE IN DETAIL: The patient was brought to the operative suite and placed on the operative table in supine position. He was confirmed to receive perioperative antibiotics as well as perioperative heparin. After induction of general anesthesia, a 15-French Foley catheter was inserted in the patient's bladder via the urethra with 10 mL in the balloon and all urine was drained from the bladder. The patient was then moved to the right modified flank position with his right side facing up and he was placed over the break of the bed, so when the bed was flexed, it would maximally expose the area between the 12th rib and the anterior superior iliac spine to maximally expose the area of his kidney. He was then secured to the bed using copious egg crate foam and silk tape. All pressure points were padded. The patient was then prepped and draped in standard sterile fashion using ChloraPrep sticks x2. A time-out was then achieved according to WHO criteria. We began the procedure by inserting a Veress needle into the intra-abdominal space. The intra-abdominal location was confirmed using the hanging drop test. We then connected out insufflation and we noted low insufflation pressures less than 6 mmHg, further confirming intra-abdominal location. The abdomen was insufflated to 15 mmHg. We then inserted an 8-mm robotic trocar to the right of midline on the patient's abdomen and connected our insufflation tubing. We then inserted a robotic camera and inspected the patient's abdomen. No untoward damage was noted from either the Veress needle placement or the trocar placement. No apparent adhesions were noted in the patient's abdomen. We then placed our additional robotic 8-mm trocars in line to the right of midline, all under direct vision. One port was placed in the right lower quadrant for the fourth robotic arm. We also inserted 12 mm and 5 mm assistant ports in the midline, again all under direct vision. The robot was then docked in a standard fashion. We used a 30-degree down scope for the remainder of the case. We began the procedure by medializing the patient's right colon. We incised along the white line of Toldt and medialized the colon as well as kocherized part of the duodenum to better expose our area of the kidney. We were able to visualize the renal hilum very soon thereafter and noted a branching renal vein as well as a renal artery. We followed the hilum cephalad and encountered the patient's adrenal gland. The adrenal gland was dissected free superiorly and laterally. This was then peeled off the kidney very carefully. We then brought in a robotic vessel sealer device to further detach the adrenal gland from its surrounding attachments medially, we identified the adrenal vein and this was ligated using the robotic vessel sealer device. Good hemostasis was noted thereafter. After this, we completely detached the adrenal gland from its surrounding attachments using again the robotic vessel sealer device. Once the adrenal gland was freed in its entirety, it was placed in an EndoCatch bag. Surgicel was placed in the adrenal bed. Again, good hemostasis was noted. The robot was then undocked and the specimen was extracted through the 12-mm port. The fascia at the 12-mm assistant port was then closed using 0 Vicryl suture in an interrupted figure-of-eight fashion. A good fascial closure was noted. All skin was closed using 4-0 Monocryl suture. Skin was then cleansed and dried and covered with skin glue. The Foley catheter was removed at the end of the case. The patient tolerated the procedure well without complication. All counts were correct x2 at the end of the case. Dr. Louis Krane was present and scrubbed for the entirety of the procedure. DISPOSITION: The patient will be allowed to convalesce in the PACU today. He will be admitted overnight for observation with likely discharge home the following day.